Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Diagnosis of Haemophilus Influenzae Type b Pericarditis by Counterimmunoelectrophoresis Peter Gaustad & Roald Bolle To cite this article: Peter Gaustad & Roald Bolle (1978) Diagnosis of Haemophilus Influenzae Type b Pericarditis by Counterimmunoelectrophoresis, Scandinavian Journal of Infectious Diseases, 10:2, 149-151, DOI: 10.3109/inf.1978.10.issue-2.10 To link to this article: http://dx.doi.org/10.3109/inf.1978.10.issue-2.10
Published online: 02 Jan 2015.
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Date: 25 March 2016, At: 23:18
Scand J Infect Dis 10: 149-151, 1978
Case Report
Diagnosis of Haemophilus influenzae Type b Pericarditis by Counterimmunoelectrophoresis PETER GAUSTAD and ROALD BOLLE From Kaptein W . Wilhelmsen og Frues Bakteriologiske Institutt and the Department of Pediatrics, Rikshospitalet. Oslo, Norway
Downloaded by [ECU Libraries] at 23:18 25 March 2016
ABSTRACT. A 6-year-old girl developed pericardial tamponade because of pericarditis caused by Haemophilus influenzae type b. Bacteriologicalcultures of the pericardial exudate were negative. The etiological diagnosis was established by counterimmunoelectrophoresis (CIE).
INTRODUCTION Purulent pericarditis is an uncommon disorder. It may be seen in infants as young as 5 weeks old (12). Untreated the disease has a mortality of 75-100 % (4, 14). Antibacterial and surgical treatment have reduced the mortality to less than 50% (14). Identification of the causal pathogen is of paramount importance. The most frequently recovered organisms are Staphylococcus aureus, Haemophilus influenzae type b, and meningococci; occasionally beta-haemolytic streptococci, pneumococci or gram-negative rods are found. From 1928 to 1976 33 cases of purulent pericarditis caused by H. influenzae type b have been reported in the literature (4). In the following we describe a patient with pericardial tamponade who was found to have pencarditis caused by H. influenzae type b. The patient had recently received antibiotics and bacteriological cultures of the pericardial exudate were negative. The etiological diagnosis was established by counterimmunoelectrophoresis (CIE).
CASE REPORT A byear-old Norwegian girl had been well until 2 weeks prior to admission, when she developed fever and sore throat. Phenoxymethyl penicillin was given for a few days. Because of severe distress with tachypnoea, paleness, and hepatomegaly she was admitted to the local hospital. She had no fever. Cultures from the nose, throat, and blood grew H. influenzae sensitive to ampicillin.
She was treated with intravenous ampicillin, diuretics, and digitalis, but her clinical condition did not improve. Chloramphenicol was added and artificial respiration was instituted. 10 days after admission to the local hospital she was transferred to the Department of Pediatrics, Rikshospitalet. On admission she was in a respirator. Examination of the heart revealed muffled heart sounds. The liver was palpated 3 cm below the right costal margin. The erythrocyte sedimentation rate was 55 mm/h, the WBC count 13 OOO/pI with a marked left shift. The ECG showed low voltage. The chest radiogram demonstrated a wide mediastinum, the cardiac silhouette could not be defined. As a therapeutic and diagnostic procedure pericardiocentesis was performed, and 960 ml of thick, yellow pus was evacuated, resulting in prompt improvement. Ampicillin (2 g) was installed into the pericardium. Culture of the pericardial fluid was negative for bacteria. However, H. iduenzae type b capsular antigen was detected by CIE. A repeat pericardiocentesis the next day yielded 200 ml of serosanguinous fluid, and ampicillin (3 g) was again installed. No organisms were grown. The patient got worse, and 3 days after admission a chest roentgenogram showed a pleural effusion on the right side. Thoracocentesis was performed. 50 ml of serosanguinous fluid was removed, and ampicillin (1 g) was installed into the pleura. No organisms were grown on cultures, and no bacterial antigen was detected in the fluid by CIE. Suspicious signs of constrictive pericarditis developed later with tachypnoea at rest, distension of neck veins, increasing hepatomegaly, and oedema. A cephalosporin was given. Pericardiectomy was performed 17 days after admission. The pericardium was found thickened and adherent to most of the surface of the heart. Pleural effusions on both sides were evacuated during the operation. Postoperatively the patient was treated with digitalis, diuretics, and intravenous carbenicillin. After one week the oedema disappeared and the hepatomegalia was greatly reduced. At the time of discharge 2 months after Scand J Infect Dis 10
150
P. Gaustad und R . Bolle
admission she had no symptoms of heart disease. The ECG was normal. The chest roentgenogram showed normal cardiac size, but a pleural effusion was still present. Treatment with digitalis was continued. Six weeks later a follow-up chest roentgenogram was normal. Digitalis medication was stopped. 19 months later she is asymptomatic.
Downloaded by [ECU Libraries] at 23:18 25 March 2016
Laboratory methods CIE was carried out by a method described by Myhre (1 I). Specimens of pericardial fluid obtained by pericardiocentesis and pleural fluid were examined for presence of certain bacterial polysaccharide antigens. Rabbit antisera to H. influenzae type b, N . meningitidis (group A, B, C), and Streptococcus pneumoniae (omnivalent) were used ( 5 ) . Examinations for precipitin bands were done against a dark background and with an oblique light source immediately after the run.
RESULTS A precipitin band formed between antisera to H. influenzae type b and the pericardial fluid, signifying a positive reaction. This was in accordance with the results obtained at the local hospital by bacteriological cultures from the nose, throat, and blood. At Rikshospitalet blood, throat, and nose cultures and cultures from the pericardial and pleural fluid did not reveal any pathogenic bacteria. A sample of the pleural fluid was negative by CIE.
Escherichia coli (8), and Pseudomonas aeruginosa ( I ) in the body fluids of patients with systemic infections. Thus, capsular antigen of H. influenzae has been detected by CIE in the serum (7), the cerebrospinal fluid (5, 11) and the synovial fluid (9). In one case the technique has been used in the diagnosis of H. influenzae pericarditis (16). During recent years an increasing incidence of infections with H. influenzae has been reported (10, 15). This emphasizes the need for rapid and specific methods of etiological diagnosis. CIE cannot replace standard bacteriological methods. As a rapid, sensitive, and specific method it is a useful adjunct in the diagnosis of an increasing number of diseases, where examinations of infected body fluids may give the etiological diagnosis, especially in cases where this is otherwise hindered by previous antibiotic therapy. ACKNOWLEDGEMENT We are grateful to Tov Omland, M.D., Director of Norwegian Defence Microbiological Laboratory for help in the CIE examinations.
REFERENCES 1. Bartram. C. E.. Jr. Crowder. J. G . . Beeler. B. & White, A.: Diagnosis of bacterial diseases by’detec,
DISCUSSION Purulent pericarditis is an uncommon serious complication to respiratory infections with H. influenzae, in which the pericardium is “seeded” as a result of bacteremia. The true incidence of bacteremia in such cases is unknown (4). In our patient H. influenzae was isolated from throat, nose, and blood specimens obtained at the local hospital. Prior to admission to Rikshospitalet the patient had been treated with antibiotics for several days, which may explain the negative cultures later on. However, the etiological diagnosis was confirmed by CIE of the pericardial fluid. This shows that CIE can provide a rapid and specific confirmation of the diagnosis despite previous antibiotic treatment and at a time when the bacteriological diagnosis is of importance for proper management of the disease. In the other studies CIE has been used to detect the capsular antigens of Neisseria meningitidis, S. pneumoniae, H. influenzae (2, 3, 6, 7 , 13),
2. 3.
4.
5.
6.
7.
8.
I
tion of serum antigens by counterimmunoelectrophoresis, sensitivity and specificity of detecting pseudomonas and pneumococcal antigens. J Lab Clin Med 83: 591, 1974. Coonrod, J. D. & Rytel, M. W.: Determination of aetiology of bacterial meningitis by counterimmunoelectrophoresis. Lancet 1: 1154, 1972. Dorff, D. J., Coonrod, J. D. & Rytel, M. V.: Detection by immunoelectrophoresis of antigen in sera of patient with pneumococcal bacteriemia. Lancet 1:578, 1971. Echeverria, P., Smith, E. W. P., Ingram, D., Sade, R. M. & Gardner, P.: Hemophilus influenzae b pericarditis in children. Pediatrics 56: 808, 1975. Fsrre, Id. & Gaustad, P.: An evaluation of two immunological methods in the diagnosis of bacterial meningitis: The effect of ultrasonic treatment of the cerebrospinal fluid. Scand J Infect Dis 9: 285, 1977. Greenwood, B. M., Whittle, H. C. & DominicRajkovic, 0.: Contercurrent immunoelectrophoresis in the diagnosis of meningococcal infections. Lancet 2:519, 1971. Ingram, D. L., Anderson, P. & Smith, I). H.: Countercurrent immunoelectrophoresis in the diagnosis of systemic diseases caused by Hemophilus influenzae type b. J Pediatr 81: 1156, 1972. McCracken, G. H., Sarff, L. D., Glade, M. D., Mize, S. G., Schiffer, M. S., Robbins, J . B., Gotschlich,
Haernophilus influenzae type b pericarditis
9.
10. 1I.
12.
Downloaded by [ECU Libraries] at 23:18 25 March 2016
13.
14.
15. 16.
15 1
E. M., grskov, I. & grskov, F.: Relationship between Escherichia coli K, capsular polysaccharide antigen and clinical outcome in neonatal meningitis. Lancet 2:246, 1974. Meritt, K., Boyle, W. E., Jr, Dye, S. K. & Porter, R. E.: Counterimmunoelectrophoresis in the diagnosis of septic arthritis caused by Hemophilus influenzae. J Bone Joint Surg [Am] 58:414, 1976. Michaels, R. H.: Increase in influenza1 meningitis. N Engl J Med 285: 666, 1971. Myhre, E. B.: Rapid diagnosis of bacterial meningitis. Demonstration of bacterial antigen by counterimmunoelectrophoresis. Scand J Infect Dis 6: 237, 1974. Nadas, A. S.: Pediatric cardiology, p. 300. Saunders, Philadelphia 1963. Nieburg, P. I., Rabinowitz, R. C. & Weiner, L. B.: Diagnosis of pneumococcal peritonitis by countercurrent immunoelectrophoresis (CIE). Scand J Infect Dis 9: 57, 1977. Okoroma, E. 0..Perry, L. W. & Scott, L. P.: Acute bacterial pericarditis in children: report of 25 cases. Am Heart J 90: 709, 1975. Smith, E. W. P., Jr & Haynes, R. E.: Changing incidence of Hemophilus influenzae meningitis. Pediatrics 50: 723, 1972. Smith, E. W. P., Jr & Ingram, D. L.: Counterimmunoelectrophoresis in Hernophilus influenzae type b epiglottitis and pericarditis. J Pediatr 86: 571, 1975.
Address for reprints:
P . Gaustad, M.D., Kaptein W . Wilhelmsen og Frues Bakteriologiske Institutt, Rikshospitalet, Oslo I , Norway
Scntrd J Infecr Dis 10
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Diagnosis of Haemophilus Influenzae Type b Pericarditis by Counterimmunoelectrophoresis Peter Gaustad & Roald Bolle To cite this article: Peter Gaustad & Roald Bolle (1978) Diagnosis of Haemophilus Influenzae Type b Pericarditis by Counterimmunoelectrophoresis, Scandinavian Journal of Infectious Diseases, 10:2, 149-151, DOI: 10.3109/inf.1978.10.issue-2.10 To link to this article: http://dx.doi.org/10.3109/inf.1978.10.issue-2.10
Published online: 02 Jan 2015.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [ECU Libraries]
Date: 25 March 2016, At: 23:18
Scand J Infect Dis 10: 149-151, 1978
Case Report
Diagnosis of Haemophilus influenzae Type b Pericarditis by Counterimmunoelectrophoresis PETER GAUSTAD and ROALD BOLLE From Kaptein W . Wilhelmsen og Frues Bakteriologiske Institutt and the Department of Pediatrics, Rikshospitalet. Oslo, Norway
Downloaded by [ECU Libraries] at 23:18 25 March 2016
ABSTRACT. A 6-year-old girl developed pericardial tamponade because of pericarditis caused by Haemophilus influenzae type b. Bacteriologicalcultures of the pericardial exudate were negative. The etiological diagnosis was established by counterimmunoelectrophoresis (CIE).
INTRODUCTION Purulent pericarditis is an uncommon disorder. It may be seen in infants as young as 5 weeks old (12). Untreated the disease has a mortality of 75-100 % (4, 14). Antibacterial and surgical treatment have reduced the mortality to less than 50% (14). Identification of the causal pathogen is of paramount importance. The most frequently recovered organisms are Staphylococcus aureus, Haemophilus influenzae type b, and meningococci; occasionally beta-haemolytic streptococci, pneumococci or gram-negative rods are found. From 1928 to 1976 33 cases of purulent pericarditis caused by H. influenzae type b have been reported in the literature (4). In the following we describe a patient with pericardial tamponade who was found to have pencarditis caused by H. influenzae type b. The patient had recently received antibiotics and bacteriological cultures of the pericardial exudate were negative. The etiological diagnosis was established by counterimmunoelectrophoresis (CIE).
CASE REPORT A byear-old Norwegian girl had been well until 2 weeks prior to admission, when she developed fever and sore throat. Phenoxymethyl penicillin was given for a few days. Because of severe distress with tachypnoea, paleness, and hepatomegaly she was admitted to the local hospital. She had no fever. Cultures from the nose, throat, and blood grew H. influenzae sensitive to ampicillin.
She was treated with intravenous ampicillin, diuretics, and digitalis, but her clinical condition did not improve. Chloramphenicol was added and artificial respiration was instituted. 10 days after admission to the local hospital she was transferred to the Department of Pediatrics, Rikshospitalet. On admission she was in a respirator. Examination of the heart revealed muffled heart sounds. The liver was palpated 3 cm below the right costal margin. The erythrocyte sedimentation rate was 55 mm/h, the WBC count 13 OOO/pI with a marked left shift. The ECG showed low voltage. The chest radiogram demonstrated a wide mediastinum, the cardiac silhouette could not be defined. As a therapeutic and diagnostic procedure pericardiocentesis was performed, and 960 ml of thick, yellow pus was evacuated, resulting in prompt improvement. Ampicillin (2 g) was installed into the pericardium. Culture of the pericardial fluid was negative for bacteria. However, H. iduenzae type b capsular antigen was detected by CIE. A repeat pericardiocentesis the next day yielded 200 ml of serosanguinous fluid, and ampicillin (3 g) was again installed. No organisms were grown. The patient got worse, and 3 days after admission a chest roentgenogram showed a pleural effusion on the right side. Thoracocentesis was performed. 50 ml of serosanguinous fluid was removed, and ampicillin (1 g) was installed into the pleura. No organisms were grown on cultures, and no bacterial antigen was detected in the fluid by CIE. Suspicious signs of constrictive pericarditis developed later with tachypnoea at rest, distension of neck veins, increasing hepatomegaly, and oedema. A cephalosporin was given. Pericardiectomy was performed 17 days after admission. The pericardium was found thickened and adherent to most of the surface of the heart. Pleural effusions on both sides were evacuated during the operation. Postoperatively the patient was treated with digitalis, diuretics, and intravenous carbenicillin. After one week the oedema disappeared and the hepatomegalia was greatly reduced. At the time of discharge 2 months after Scand J Infect Dis 10
150
P. Gaustad und R . Bolle
admission she had no symptoms of heart disease. The ECG was normal. The chest roentgenogram showed normal cardiac size, but a pleural effusion was still present. Treatment with digitalis was continued. Six weeks later a follow-up chest roentgenogram was normal. Digitalis medication was stopped. 19 months later she is asymptomatic.
Downloaded by [ECU Libraries] at 23:18 25 March 2016
Laboratory methods CIE was carried out by a method described by Myhre (1 I). Specimens of pericardial fluid obtained by pericardiocentesis and pleural fluid were examined for presence of certain bacterial polysaccharide antigens. Rabbit antisera to H. influenzae type b, N . meningitidis (group A, B, C), and Streptococcus pneumoniae (omnivalent) were used ( 5 ) . Examinations for precipitin bands were done against a dark background and with an oblique light source immediately after the run.
RESULTS A precipitin band formed between antisera to H. influenzae type b and the pericardial fluid, signifying a positive reaction. This was in accordance with the results obtained at the local hospital by bacteriological cultures from the nose, throat, and blood. At Rikshospitalet blood, throat, and nose cultures and cultures from the pericardial and pleural fluid did not reveal any pathogenic bacteria. A sample of the pleural fluid was negative by CIE.
Escherichia coli (8), and Pseudomonas aeruginosa ( I ) in the body fluids of patients with systemic infections. Thus, capsular antigen of H. influenzae has been detected by CIE in the serum (7), the cerebrospinal fluid (5, 11) and the synovial fluid (9). In one case the technique has been used in the diagnosis of H. influenzae pericarditis (16). During recent years an increasing incidence of infections with H. influenzae has been reported (10, 15). This emphasizes the need for rapid and specific methods of etiological diagnosis. CIE cannot replace standard bacteriological methods. As a rapid, sensitive, and specific method it is a useful adjunct in the diagnosis of an increasing number of diseases, where examinations of infected body fluids may give the etiological diagnosis, especially in cases where this is otherwise hindered by previous antibiotic therapy. ACKNOWLEDGEMENT We are grateful to Tov Omland, M.D., Director of Norwegian Defence Microbiological Laboratory for help in the CIE examinations.
REFERENCES 1. Bartram. C. E.. Jr. Crowder. J. G . . Beeler. B. & White, A.: Diagnosis of bacterial diseases by’detec,
DISCUSSION Purulent pericarditis is an uncommon serious complication to respiratory infections with H. influenzae, in which the pericardium is “seeded” as a result of bacteremia. The true incidence of bacteremia in such cases is unknown (4). In our patient H. influenzae was isolated from throat, nose, and blood specimens obtained at the local hospital. Prior to admission to Rikshospitalet the patient had been treated with antibiotics for several days, which may explain the negative cultures later on. However, the etiological diagnosis was confirmed by CIE of the pericardial fluid. This shows that CIE can provide a rapid and specific confirmation of the diagnosis despite previous antibiotic treatment and at a time when the bacteriological diagnosis is of importance for proper management of the disease. In the other studies CIE has been used to detect the capsular antigens of Neisseria meningitidis, S. pneumoniae, H. influenzae (2, 3, 6, 7 , 13),
2. 3.
4.
5.
6.
7.
8.
I
tion of serum antigens by counterimmunoelectrophoresis, sensitivity and specificity of detecting pseudomonas and pneumococcal antigens. J Lab Clin Med 83: 591, 1974. Coonrod, J. D. & Rytel, M. W.: Determination of aetiology of bacterial meningitis by counterimmunoelectrophoresis. Lancet 1: 1154, 1972. Dorff, D. J., Coonrod, J. D. & Rytel, M. V.: Detection by immunoelectrophoresis of antigen in sera of patient with pneumococcal bacteriemia. Lancet 1:578, 1971. Echeverria, P., Smith, E. W. P., Ingram, D., Sade, R. M. & Gardner, P.: Hemophilus influenzae b pericarditis in children. Pediatrics 56: 808, 1975. Fsrre, Id. & Gaustad, P.: An evaluation of two immunological methods in the diagnosis of bacterial meningitis: The effect of ultrasonic treatment of the cerebrospinal fluid. Scand J Infect Dis 9: 285, 1977. Greenwood, B. M., Whittle, H. C. & DominicRajkovic, 0.: Contercurrent immunoelectrophoresis in the diagnosis of meningococcal infections. Lancet 2:519, 1971. Ingram, D. L., Anderson, P. & Smith, I). H.: Countercurrent immunoelectrophoresis in the diagnosis of systemic diseases caused by Hemophilus influenzae type b. J Pediatr 81: 1156, 1972. McCracken, G. H., Sarff, L. D., Glade, M. D., Mize, S. G., Schiffer, M. S., Robbins, J . B., Gotschlich,
Haernophilus influenzae type b pericarditis
9.
10. 1I.
12.
Downloaded by [ECU Libraries] at 23:18 25 March 2016
13.
14.
15. 16.
15 1
E. M., grskov, I. & grskov, F.: Relationship between Escherichia coli K, capsular polysaccharide antigen and clinical outcome in neonatal meningitis. Lancet 2:246, 1974. Meritt, K., Boyle, W. E., Jr, Dye, S. K. & Porter, R. E.: Counterimmunoelectrophoresis in the diagnosis of septic arthritis caused by Hemophilus influenzae. J Bone Joint Surg [Am] 58:414, 1976. Michaels, R. H.: Increase in influenza1 meningitis. N Engl J Med 285: 666, 1971. Myhre, E. B.: Rapid diagnosis of bacterial meningitis. Demonstration of bacterial antigen by counterimmunoelectrophoresis. Scand J Infect Dis 6: 237, 1974. Nadas, A. S.: Pediatric cardiology, p. 300. Saunders, Philadelphia 1963. Nieburg, P. I., Rabinowitz, R. C. & Weiner, L. B.: Diagnosis of pneumococcal peritonitis by countercurrent immunoelectrophoresis (CIE). Scand J Infect Dis 9: 57, 1977. Okoroma, E. 0..Perry, L. W. & Scott, L. P.: Acute bacterial pericarditis in children: report of 25 cases. Am Heart J 90: 709, 1975. Smith, E. W. P., Jr & Haynes, R. E.: Changing incidence of Hemophilus influenzae meningitis. Pediatrics 50: 723, 1972. Smith, E. W. P., Jr & Ingram, D. L.: Counterimmunoelectrophoresis in Hernophilus influenzae type b epiglottitis and pericarditis. J Pediatr 86: 571, 1975.
Address for reprints:
P . Gaustad, M.D., Kaptein W . Wilhelmsen og Frues Bakteriologiske Institutt, Rikshospitalet, Oslo I , Norway
Scntrd J Infecr Dis 10
